This is a continuation of the interview with Dr. Aron Wolf by William Schneider and Karen Brewster on December 7, 2010 at his private psychiatric office in Anchorage, Alaska.
Digital Asset Information
Project: Alaska Mental Health Trust History
Date of Interview: Dec 7, 2010
Narrator(s): Dr. Aron Wolf
Interviewer(s): Bill Schneider, Karen Brewster
Transcriber: Carol McCue
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Section 1: Connection between vocational rehabilitation program and mental health services, and thoughts about the practice of psychiatry as giving medication versus using talk therapy.
Section 2: Use of technology to keep in contact with patients and need for insurance billing to understand this process.
Section 3: Assessment of Harborview Hospital in Valdez, Alaska for the care of the developmentally disabled.
Section 4: The care of people at Harborview Hospital in Valdez versus what came afterwards.
Section 5: Examples of successes and challenges of community based mental health centers in Alaska.
Section 6: Problems faced by behavioral health aides in the villages.
Section 7: Improvements in the delivery of mental health services to rural Alaska, and a lack of trained psychiatrists available in Anchorage and to provide services in the private sector.
Section 8: Practicing psychiatry in the private sector versus the public sector, and the types of patient care provided.
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After clicking play, click a section of the transcript to navigate the audio or video clip.
Section 1: DR. ARON WOLF: Well, one of the other major influences, and psychiatry has always been a part of this, is vocational rehabilitation. The division ‑‑ voc rehab is funded by both the feds and ‑‑ and the state. And they have been ‑‑ their beneficiaries are anybody with a disability where that disability keeps them from employment.
And so they've been very influential in directing mental health services and paying for a lot of the mental health services around the state.
BILL SCHNEIDER: That's interesting.
DR. ARON WOLF: The ‑‑ and Dr. Doolittle is their consultant for Fairbanks, so of course, as chair of the Trust, he's knowledgeable about that, and ‑‑ and I've been ‑‑ Dr. Langdon was their first statewide medical consultant, and at his death in '81, I've been that since then.
So, you know, there are a series of medical consultants, but we review the charts, we make recommendations, they have money to spend, a lot of it's federal money, federal mandate money.
BILL SCHNEIDER: Yeah.
DR. ARON WOLF: So that's a nice adjunct that's actually only grown over the ‑‑ it's been there all this time, it's grown over the years.
BILL SCHNEIDER: Just a general personal question. What ‑‑ what do you see in the way of this relationship between psychiatry as ‑‑ as medicine and psychiatry as therapy, dialogue therapy, what I would call?
DR. ARON WOLF: Um. Yes.
BILL SCHNEIDER: Yes, all of the above?
DR. ARON WOLF: Yes, all of the above.
There ‑‑ there have been any number of really wonderful studies that say that the best results are when you combine talking therapy and a judicious use of medications, of appropriate medications. Now, you know, this is almost from the time that Thorazine was developed in 1954, you know. This ‑‑ this is where ‑‑ where it went.
I ‑‑ I was trained in Baltimore, and one of ‑‑ one of the places that I was trained was Chestnut Lodge, and Chestnut Lodge is where Frieda Fromm‑Reichmann was from "I Never Promised You a Rose Garden," and actually I have had the privilege of meeting the woman who wrote that book, and she's wonderful. But Frieda Fromm‑Reichmann and Hunter Will (phonetic) were some of my supervisors, so I got trained in all of that very early intensive talking, analytic kind of thing.
The medications are important. I'm sure you've heard from Jim Gottstein that he feels that they are significantly overused, they probably are significantly overused, really a judicious use of the medications, along with an interpersonal relationship, which goes to your questions earlier about the doc over the television. You know, but yeah. Knowing your doc. But you don't necessarily have to know your doc face‑to‑face if that can't happen. You know. But yes. Having a relationship is really, really, really important.
Section 2: BILL SCHNEIDER: Okay. Well, what are we missing?
DR. ARON WOLF: I ‑‑ I think one of the ‑‑ one of the places that we're missing is ‑‑ and I know people are trying to develop this, is the use of technology. For the moment, you can't bill, and there's no mechanism of billing for e‑mails. If you're in your office, use ‑‑ the use of Skype or other things. I actually occasionally do both.
I have some oil folks who have been sent to Kazakhstan, they can't get here for six months at a time. Having that relationship continue by e‑mail, by occasional face‑to‑face where I've said ‑‑ said to them, you know, please sign here, you know, you know this is an open ‑‑ potentially open mic, it's worked wonderfully.
Now, how do we get the technology so that it really meets HIPAA so that we don't have to get them to double sign that they understand this. So I ‑‑ I think that, I think the fact that we're moving by the national health law to electronic health records, and even in a small office like this, I'm ‑‑ I'm in the process.
So we're going toward more quality, we're going toward more use of all the ‑‑ all the tools that we have with it, and I think an understanding, at least in Alaska, of ‑‑ of the issue of the proper use of medication. So that ‑‑ that you're really are trying to give folks as they have their mental illness issues that you're not just trying to lie them out on the floor.
BILL SCHNEIDER: Yeah. Yeah. Well --
Section 3: KAREN BREWSTER: You mentioned vocational rehabilitation, which made me think about Harborview Hospital, which is an institution we haven't talked very much about in this project, and I'm wondering if you had any knowledge of it and experience with it.
DR. ARON WOLF: Oh, yeah. Oh, yeah. One ‑‑ one of the places I consulted to was the fledgling Valdez Mental Health Center.
And I know the people in the DD community thought Harborview was awful for the developmentally disabled. I thought ‑‑ they thought Harborview was awful? Harborview was not awful. Harborview was ‑‑ did a ‑‑ a very wonderful job for their residents.
The City of Valdez was very involved in Harborview. A number of the Valdez residents would take the Harborview residents out to their homes and be involved with them and tried to give them a home‑like atmosphere. Their real families had no access to them, and that ‑‑ that was the problem.
What was actually happening at Harborview was really positive lots of the time. Really, really positive. And in its own way, very sad that ‑‑ that it demised, if you will. So if Harborview had been in a place that was more accessible to the families and where they also could have been part of that, I think some form of it would still be functioning.
KAREN BREWSTER: So what were the criticisms of it?
DR. ARON WOLF: Oh. The criticisms, is you sent ‑‑ the state sent Johnny off to this place, and he was packed away, and nothing was happening. Well, the family, lots of the families, didn't know what was happening. Lots of the families certainly couldn't afford to get there.
They ‑‑ they were mourning the loss of their family member because they had no access to their family member, and all of that engendered a lot of anger on the part of the families.
And then there was a movement within the DD community for home‑based programs. And at least ‑‑ and I ‑‑ and I've not kept track, but at least at the beginning, the places that a number of the Harborview folks were placed in after Harborview were nowhere near as good. Nowhere near.
I mean, they ‑‑ they were ‑‑ they were in an environment that was, in many ways, loving, and they ‑‑ they were taken out of there and placed in a new place, in Anchorage, you know, where they couldn't walk around. I mean, one of the nice things about Valdez is that, you know, they could be outside and go to the supermarket or go down to the rec center or whatever or go down to the university, and everybody would ‑‑ you know, if they looked lost, somebody would bring them back.
So ‑‑ so all of that was lost.
Now, in the long run, will it be better? Maybe. But we ‑‑ we lost a good thing because it was ‑‑ it was in the wrong place at the wrong time.
Section 4: KAREN BREWSTER: Similar criticisms were made of Morningside, I believe, that, you know, family members were taken away and never came back to the ‑‑
DR. ARON WOLF: Exactly. Exactly. Exactly. Well, and ‑‑ but a lot of these ‑‑ of the developmentally disabled folks, although family can be closer now, they can't live in there. I mean, their ‑‑ their disabilities are such that they still need to be in a supportive living environment.
And ‑‑ and so yes, there's more access to them, somebody needs to do a study to see whether families are actually using that access. Are they seeing their family members even though they are in Anchorage? I don't think we've done a study on that.
BILL SCHNEIDER: Yeah. That was going to be my question is ‑‑ is how do families deal with the loss of ‑‑ of a member knowing that they are probably getting better care at another facility, but ‑‑
DR. ARON WOLF: A lot of anger. Well, and the fact that ‑‑ that Harborview was really remote and they couldn't afford it, there was just a lot of anger and regret and guilt and whatever of shipping Johnny off to that place.
BILL SCHNEIDER: Have people looked at that in terms of the family itself?
DR. ARON WOLF: Oh, yeah. Yeah. Not here, but in the Lower 48, what ‑‑ what that does.
And ‑‑ and the lobby for the rights of the developmentally disabled has been a very strong lobby for a long time, they've done a lot of really good things, but there was this incessant pounding about you've got to close Harborview for years and years and years and years. And it was sort of like this is happening here, somebody should take a look at what's happening at Harborview here, and they didn't because they were of narrow focus with really good intentions.
Section 5: KAREN BREWSTER: That leads me to ask about the whole community mental health movement and the effectiveness of that for patients.
DR. ARON WOLF: It's ‑‑ well, I ‑‑ in the places where it works well, it's really nice.
A stellar example of one that works well is Petersburg. Their staff has been there a long while, they really care, people see it as a part of the community, it's ‑‑ it's as good an example of how this kind of thing works as you could possibly want.
I'm not sure where YK is now, but during the years I was there, most of their staff was Yup'ik, and go to the villages and they were accepted and caring and, you know, the village trips were ‑‑ were wonderful, I mean, and they ‑‑ you get off the plane and they'd always have people out there and they'd hug the ‑‑ the workers and it was wonderful.
Now, I felt privileged, if you will, to be a part of it, but, you know, people would say, oh, Doctor, thank you, but it wasn't me. It really was them.
The more urban ones have gotten bogged down over the years in administrative things, and fund‑raising and ‑‑ and tried to do a number of programs, but really, a number of them have not been anywhere as near as flexible as they probably need to be.
And, they have had a terrible time in recruiting staff. Jerry Jenkins over here at Anchorage Community Mental Health has been functioning on Rent‑A‑Docs, locum tenens, for four or five years. He really has been unable to attract and keep psychiatrists there, and so the other folks do their job in as good a way as they can, but some of the flexibility of what all that was meant to be has gotten lost in the translation.
So, you know, I think the basics are there, it needs to get tinkered with, some of the tinkering fairly -- fairly substantial.
Section 6: KAREN BREWSTER: I have just one more question. You mentioned ‑‑ you were talking about the telemedicine and how the community mental ‑‑ community health aides have utilized that. Isn't there a program for mental health behavioral specialists following the community health aide model?
DR. ARON WOLF: There is.
KAREN BREWSTER: What are your thoughts on that?
DR. ARON WOLF: Oh, that ‑‑ that's great. It's been a problem in a number of villages because if somebody's labeled the mental health aide, either everybody comes to them, or this is Auntie Sue, and ‑‑ and you don't want to tell your problems to Auntie Sue who is going to tell it to Uncle Henry who is going to ‑‑ you know. And so in some ‑‑ some ways, some ‑‑ it's better if it's just one of the village health aides who doesn't have that label with them.
When I was at Providence, we had a grant to help the North Slope Borough reform ‑‑ reformulate their mental health programs. They ‑‑ instead of the Native corporation ‑‑ well, they do it in conjunction with the Native corporation, but ‑‑ but the borough actually runs the mental health programs.
And they did have mental health aides, and they would burn them out in, you know, six months. And especially in the Anaktuvuk and some of the more remote villages.
So ‑‑ so some of the problem is with how the villages, the milieu of the villages, some of it ‑‑ but it isn't the training. I think the general health aides really need some of this training, they do very well.
I mean, one of the things that I used to find aghast is the Public Health Service does something called auto refill on meds. And so somebody prescribes, you know, antipsychotic, and they send a year's worth. Now, 20 pills will kill you. Send a thousand pills. To my knowledge, there was nobody who ‑‑ at least no one in my care, who ever committed suicide on their auto refill.
They would hang themselves, they would run themselves through the ice, they ‑‑ they’d slice their wrists, they would do whatever. They'd take other pills. They would never take their prescribed pills.
So there was a respect for the auto refill kind of thing because I would look on a shelf and I'd be talking to somebody who is really depressed, and there's enough, you know, to kill seven people in this jar. You know, they ‑‑ they would ‑‑ they would respect that. Which I thought was a ‑‑ a fascinating sort of sub context to this.
Section 7: KAREN BREWSTER: So you think the behavioral health aide specialists would be able to handle the problems compared to, I mean, a trained psychiatrist travelling to those villages?
DR. ARON WOLF: I think a behavioral ‑‑ a health aide with behavioral training who has access to telemedicine can do it.
I mean, if you go back to the old days, prior to our even going ‑‑ a number of us going out there, that the health aide in the village would have radio traffic, you know, two hours on a Wednesday, and maybe they ‑‑ the radio traffic would talk to the social worker in Bethel who would then call the psychiatrist in Anchorage, and then respond three days later to the health aide.
You can now do ‑‑ do, you know, your hour to do your six patients this week with a psychiatrist who you're seeing, talking to, who you know, who you could e‑mail in between. You know, that ‑‑ huge change. And much better. And much more access. Much more access.
KAREN BREWSTER: Are there ‑‑ are there changes that have happened that have maybe been not so good?
DR. ARON WOLF: We're actually, in many ways, down psychiatrists from where we were 10 or 15 years ago. And, although a number of us don't like to admit it, we're aging, and a number of us are going to age out of this. So we are 49th in the nation per hundred thousand for psychiatrists. And it's a huge problem.
API functions a lot on Rent‑A‑Docs. Community Mental Health Center here does, Fairbanks does. Dr. Stilner in Juneau has five psychiatrists, he ‑‑ Juneau is great. Juneau has ‑‑ has enough.
SEARHC Hospital in Sitka has enough.
But there ‑‑ Dr. Winn in Anchorage does ‑‑ for 22 years has been going one week a month to Ketchikan, and he still does. But someday he's going to stop doing that. And so ‑‑ so the recruitment of that, we ‑‑ we are ‑‑
I don't know whether we talked to Alex von Hafften, he's a psychiatrist, he sort of inherited the psychiatry WAMI program, a number of us have done it over the years, but he has been working with the Trust and the state, he had been working with Delisa at the Trust and the state to do a full‑fledged psychiatric residency here in Anchorage. Hopefully get funded this year and start in 2012.
BILL SCHNEIDER: That's going to be great.
DR. ARON WOLF: But those folks won't graduate until 2016, so this is not an immediate fix.
But there ‑‑ there is that piece of, you know, if ‑‑ if four or five of us retired tomorrow, Anchorage would be in terrible shape.
As an example, Langdon had seven people, or Providence Behavioral Medical Group, is what it's called these days. Somebody at Providence decided to really be difficult about pay to the psychiatrists.
Six of their seven psychiatrists left. They left this gaping hole. Four of them went to the VA, and that's great for the VA system, but left this huge gaping hole in the private practice in Anchorage. And so we're thinner in many ways than we were many, many years ago.
BILL SCHNEIDER: Pretty vulnerable.
DR. ARON WOLF: We're very vulnerable, both in the public sector and the private sector, and I'm really pleased that the Trust has gotten into that kind of recruitment, as well. That's another wonderful thing the Trust's doing.
Section 8: KAREN BREWSTER: What's the difference between private sector and public sector psychiatry and services?
DR. ARON WOLF: Well, interesting, if you go to public meetings, you never hear that there's a private sector. Yeah, you go to all these meetings, and hmm, but the reality is that almost all of us in the private sector have had contracts in the public sector all these years. I mean, we ‑‑ we've all consulted to all the community mental health centers.
Almost everybody. Almost everybody has had contracts to do that, or they ‑‑ they worked at API to help out, or they've worked at the mental health center here.
So the private sector, and the public sector we call that we ‑‑ in the private sector we see the walking wounded.
But you ‑‑ to put that more politely, if you're going to run a private office, you're going to see folks who are not chronic ‑‑ chronic and severe, and ‑‑ and where you could handle the acuity on an outpatient practice.
The other issue with that, and again, which goes to access, which the mental health center is working on, is nobody in the private sector can afford to take all the Medicare or Medicaid people that would like to come and see them. You can't afford it. They pay 40 cents on the dollar.
So most of us have taken the people who have aged into Medicare and Medicaid and an occasional referral, but we can't afford to keep the doors open if you go more than that. And so even in this little practice, I get calls daily, and Panup (phonetic) has to apologize, you know, we can't, our quota is full. We can not.
And so they are being seen by Anchorage Neighborhood Health or ‑‑ and the community health ‑‑ health center, the mental health center, their grants say chronic and severe, so the person with depression or anxiety can't get in there either. Because their grant doesn't pay for it, nor do they have the staff.
So those are some of the ‑‑ the access issues and ‑‑ and staff issues that need to be addressed as ‑‑ as we go forward. Okay?
BILL SCHNEIDER: Thank you very much.
DR. ARON WOLF: You're welcome.